As rates of suicide, homelessness and mental illness continue to spike across the County, the Los Angeles Department of Mental Health is targeting new strategies to improve the underperforming status quo of mental health care.

The department is lobbying for an exemption from the longstanding Medicaid exclusion of mental health care facilities with more than 16 beds. Additionally, it is working to strengthen discharge protocols and outpatient care at these facilities in an effort to break cycles of repeat inpatient stays. 

When Medicaid was established in 1965, it explicitly prohibited states from receiving Medicaid payments for Institutions of Mental Disease (IMDs), which the law defines as “a hospital, nursing facility, or other institution of more than 16 beds, that is primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases, including medical attention, nursing care, and related services.”

At the time, the intention behind the IMD exclusion was to disincentivize institutionalization of mentally ill individuals, following widespread outrage over patient abuse in the asylum system, and replace it with a system of community mental health care. 

Such a system never materialized and the exclusion has made it difficult for patients to access mental health care nationwide, which in turn has led many severely mentally ill individuals into homelessness. 

“Antiquated federal policies put in place 50 years ago, have granted systemic barriers to healing and housing to some of our society’s most vulnerable individuals,” said County Supervisor Kathryn Barger, in a May 24 media briefing. “Those policies combined with the abuse and improvement of supply of street drugs have created a deadly cocktail. As a result, we have individuals who suffer from addiction and psychosis left to die on our streets.”

In November 2018, the Centers for Medicaid and Medicare Services announced that it would accept applications from states that wished to apply for an IMD exclusion waiver. The Board of Supervisors and the County Department of Mental Health, acted immediately and urged Governor Newsom and the California Department of Healthcare Services to apply for the waiver. 

“I believe three years ago roughly … we were informed by CMS at the federal level that states can apply for a waiver. The day I got that email I called the Department of Health Care Services and said ‘let’s go after it.’ Well still it still hasn’t happened; it will happen,” said Dr. Jonathan Sherin, director of the Department of Mental Health. 

According to Sherin, the state is now in the process of applying for a waiver, although he wishes they had taken action quicker. In addition, DMH is lobbying to repeal the IMD exclusion at a federal level and helped US Congresswoman Grace Napolitano, who represents California’s 32nd District, author a bill seeking to achieve that repeal. 

“There’s no intention in this department or in this county to warehouse people, but it’s important that we have enough funding to support a network of treatment beds that’s adequate given the demand,” said Sherin. “We see the demand every day, certainly in our streets.”

At the same time as DMH lobbies for a waiver, it is working on improving the care at mental health care facilities in LA County. Currently, there is a focus on providing stronger outpatient care and discharge plans so that patients are better supported and follow through with their treatment after exiting the facility. 

“We’d better make sure that after that period of intensive treatment, and in the achievement of stability, that we don’t lose ground, and that individuals are brought back into the community with housing, with other shelter opportunities, and the treatment team that’s aware of what’s gone on understands the different types of treatment that had been delivered, what’s worked, what the medication regimen is,” said Sherin.

Oftentimes an individual experiencing extreme mental illness may be hospitalized for a 72 hour psychiatric hold and then discharged with little more than a card in their hand with a number to call for more help. In order to maintain stability long-term, many patients need secure housing, a strong support network, encouragement to continue taking medication, and easy access to follow up care. 

“The average person will always choose the path of least resistance. A patient who is suffering from mental illness will only gain access to these treatment services if the process is simplified before they’re discharged and reintroduced to the community,” said Jeff Acosta, director of behavioral health services at Pacifica Hospital, in a May 24 media briefing. “Patients will only maintain these engagements if the system is flexible enough to work with where they are.”